Diuresis Efficacy in Ambulatory Congested HeartFailure Patients: Intrapatient Comparison of 3 Diuretic Regimens (DEA-HF).

Abstract

Limited evidence exists regarding efficacy and safety of diuretic regimens in ambulatory, congestion-refractory, chronic heart failure (CHF) patients. The authors sought to compare the potency and safety of commonly used diuretic regimens in CHF patients. A prospective, randomized, open-label, crossover study conducted in NYHA functional class II to IV CHF patients, treated in an ambulatory day-care unit. Each patient received 3 different diuretic regimens: intravenous (IV) furosemide 250mg; IV furosemide 250mg plus oral metolazone 5mg; and IV furosemide 250mg plus IV acetazolamide 500mg. Treatments were administered once a week, in 1 of 6 randomized sequences. The primary endpoint was total sodium excretion, and the secondary was total urinary volume excreted, both measured for 6 hours post-treatment initiation. A total of 42 patients were recruited. Administration of furosemide plus metolazone resulted in the highest weight of sodium excreted, 4,691mg (95%CI: 4,153-5,229mg) compared with furosemide alone, 3,835mg (95%CI: 3,279-4,392mg; P = 0.015) and to furosemide plus acetazolamide 3,584mg (95%CI: 3,020-4,148mg; P = 0.001). Furosemide plus metolazone resulted in 1.84L of urine (95%CI: 1.63-2.05 L), compared with 1.58L (95%CI: 1.37-1.8); P= 0.039 collected following administration of furosemide plus acetazolamide and 1.71L (95%CI: 1.49-1.93 L) following furosemide alone. The incidence of worsening renal function was significantly higher when adding metolazone (39%) to furosemide compared with furosemide alone (16%) and to furosemide plus acetazolamide (2.6%) (P< 0.001). In ambulatory CHF patients, furosemide plus metolazone resulted in a significantly higher natriuresis compared with IV furosemide alone or furosemide plus acetazolamide.